- Cancer means there is a growth that is not under normal control of the body. The cells replicate faster than usual and do not adhere together normally. This means the cells can invade local structures and the blood stream/lymphatic system.
- Breast cancer occurs when abnormal cells form a mass of extra tissue (a tumour) in the breast.
- Breast cancer is a general term for several different types of cancer that occur in the breast.
- The disease can be discovered by examination of the breasts (by yourself or a physician), mammography, ultrasound testing and/or biopsy.
- Treatment depends on the stage and type of the cancer, as well as your age and health.
- The two main categories of breast cancer are lobular and ductal carcinomas. Each has subtypes, which differ in their potential to spread to other body tissues. Treatment of breast cancer involves local and systemic treatment. Different specialists should be involved to optimise the treatment regime.
Breast cancer is a general term for different types of cancer that develop from breast tissue cells. When abnormal cells divide in an uncontrolled manner, they can form a mass of extra tissue, or tumour, which can be benign or malignant. Benign tumour cells do not spread to other parts of the body, can usually be removed and do not recur. Malignant (cancerous) tumour cells can invade nearby tissues and break away from the primary tumour to form secondary tumours (metastases) elsewhere in the body.
The breast and lymph nodes
The breast contains 15 to 20 sections, or lobes. Each lobe has many smaller lobules or glands. Ducts transport milk from the glands to the nipple. Stroma (fatty tissue and ligaments) surrounds the ducts and lobules. The breast is supplied with blood and lymph vessels. Lymph vessels carry tissue fluid, or lymph, which contains immune system cells. Lymph vessels lead to small glands, called lymph nodes (collections of immune system cells). Lymph node clusters draining from the breast occur under the arm, above the collarbone, in the chest and elsewhere in the body.
Most cancers begin in ducts or lobules; occasionally, tumours form in non-glandular tissue. Breast tissue fluid drains into underarm lymph nodes, which filter lymph and may form a barrier against cancer cells. Cancer cells may spread to the lymph nodes or may spread around the body to other organs via the blood system. Usually, the lymph nodes are affected first; thereafter the organs most likely to be affected are the lungs, liver, bone and brain. Once the cancer has spread to the axillary (underarm) lymph nodes, it is likely to have spread in the blood stream to other organs.
Types of breast cancer
Breast cancer is also categorised as invasive (infiltrating) or non-invasive (in situ). Invasive cancer can grow directly into other parts of the body, or travel in blood or lymph. Non-invasive cancers may become invasive, but usually do not spread, unless they have an invasive component.
Invasive cancers may exist with non-invasive cancers. The cancer can be localised or multifocal. Occasionally, more than one primary tumour may be present at the same time.
These are some of the more common types of breast cancer:
- Infiltrating/Invasive Ductal Carcinoma (IDC) comprises 65 to 85 percent of cases. It begins in milk duct cells and can break through duct walls to invade fatty tissue. It can metastasize (spread) via blood or lymph. On a mammogram it is usually revealed as an irregular mass, microcalcifications or both. It may appear as a lump, which usually feels harder than a benign lump.
- Infiltrating/Invasive Lobular Carcinoma (ILC) accounts for 5 to 10 percent of cases. It originates in milk-producing lobes, and can spread to fatty tissue and elsewhere in the body. On a mammogram, it may appear similar to IDC, but physical examination does not usually reveal a hard mass – rather a vague thickening of tissue. It can occur in more than one place in the breast (multicentric/multifocal), or in both breasts simultaneously (bilateral).
- Three slow-growing invasive subtypes are Medullary, Mucinous and Tubular Carcinomas, together representing about 12 percent of cases. They have a better prognosis than other more common invasive cancers.
- Inflammatory Carcinomais an IDC subtype. Typically the breast becomes red, swollen and warm, and the skin thickens and may develop small bumps. This is due to rapid cancerous growth which blocks lymph vessels. In 90 percent of cases, cancer has spread to the lymph nodes at diagnosis. Prognosis is poor: this cancer is aggressive and is generally treated with chemotherapy. Inflammatory cancer accounts for 1 to 4 percent of cases.
- Paget's disease starts in milk ducts and can spread to the nipple and areola, causing crusting and scaling. There is usually a history of nipple inflammation or discomfort. It may be associated with in-situ or infiltrating carcinoma. If no lump can be felt, and a biopsy shows no invasive cancer, prognosis is good. The treatment is similar to invasive cancers.
- Soft Tissue Tumours: Tumours may originate in the supportive tissue of the breast. These tumours are uncommon and tend to have a good outcome.
- As more women have regular mammograms, doctors are detecting more "non-invasive" or pre-cancerous conditions before they become full-blown cancers. They include the following:
- Ductal Carcinoma In Situ (DCIS), the most common non-invasive type, occurs when cancer cells fill ducts but haven't yet spread through the walls into fatty tissue. Most women diagnosed at this stage can be cured. Without treatment, 25 percent of cases lead to invasive cancer within 10 years. Therefore, DCIS is treated as if it were cancer – with mastectomy or lumpectomy (removal of the tumour and a surrounding rim of normal tissue). As it is not an invasive cancer, radiotherapy is not generally used as first-line treatment. Chemotherapy has no role in its management.
- Lobular Carcinoma In Situ (LCIS) has no symptoms or characteristic mammography pattern. It usually occurs in multiple sites in the same breast. The risk of developing invasive cancer with LCIS is approximately one percent per year, with an equal chance of it occurring in either breast, regardless of which breast had LCIS initially. LCIS is less common and less threatening than DCIS. It develops in milk-producing lobes and, when treated, does not penetrate lobule walls. LCIS does not usually become invasive itself, but may increase the risk of developing invasive cancer. For every 1 000 women with LCIS, 7.2 develop cancer within 30 years. Women with LCIS should have a mammogram and two or three physical exams each year.
Causes and risk factors
The cause is unknown and may include several genetic, environmental, nutritional and hormonal factors.
The following risk factors have been identified:
- Female gender: 11 percent of women develop breast cancer. (European figures based on a life expectancy of 76 years)
- More advanced age: 77 percent of women diagnosed with breast cancer are over 50.
- Having one first-degree relative (mother, sister or daughter) with breast cancer doubles risk; having two increases risk five-fold.
- Approximately 5 to 10 percent of breast cancers are the result of inherited mutations (changes) of the genes BRCA1 and BRCA2, which make proteins that help prevent cancerous growth. This cancer-preventing function is less effective with a mutated gene, and 50 to 60 percent of women with BRCA1 or BRCA2 mutations develop breast cancer by age 70.
- Risk increases significantly if you have had cancer of the breast, ovaries, uterus or colon. Cancer in one breast means there is a 1 percent chance per year of developing cancer in the other breast.
- When a biopsy indicates abnormal cells that are not yet cancerous (atypical hyperplasia), there is moderately increased risk of developing cancer in future. Atypical hyperplasia is a benign condition associated with abnormal growth of cells. A young patient with this diagnosis is very likely to develop a cancer.
- Risk increases slightly if you have had a benign breast lump.
- Having had chest area radiation therapy in childhood or youth increases risk.
- Obesity (being overweight) is a possible risk, especially after menopause.
- Diet high in saturated animal fats may increase risk.
- Compared to non-drinkers, women who consume one alcoholic drink daily may have a small increase in risk; those who have two to five drinks daily have about 1.5 times the risk.
- Exposure to oestrogen increases risk. Oestrogen stimulates cell division: the more cells divide, the more likely it is that some may become cancerous.
- Women with early onset of menstruation, late menopause, a menstrual cycle shorter or longer than average, no pregnancies or first pregnancy after 30, have slightly higher risk.
- Using oral contraceptives may slightly increase risk. Women who stopped using oral contraceptives over 10 years ago do not appear to have increased risk.
- More than 8 years of hormone replacement therapy (HRT) increases the risk. Risk returns to that of the general population within five years of stopping HRT.
- Recent research suggests that smoking may increase the risk.
Who gets it?
As more women have mammograms, and with improved detection and treatment options, rates of new cases of breast cancer have increased in Europe. South African statistics are unreliable. The rate of death from all types of breast cancer has not increased, however, as treatment is getting more effective. Breast cancer is still the most common cancer in women.
The disease is more common in older women, urban areas, higher socio-economic groups, unmarried women and Jewish women. Caucasians (especially of northern European descent) are slightly more at risk. Asian and Hispanic women have lower risk. Incidence in black women, specifically those of African descent, is increasing.
Signs and symptoms
Symptoms are not obvious in the early stages. Any woman should seek advice if she notices any change in her breast. Later symptoms may include:
- Breast lumps: these are usually painless, but some cause a prickly sensation.
- Change in nipple appearance: the shape or the skin may change.
- Unusual nipple discharge: especially stained with blood
- Change in the skin of the breast
- A lump or swelling under the arm
Occasional symptoms include:
- Breast swelling
- Vague discomfort in the breast
- Breast pain or tenderness
- Change in breast contour, texture or temperature
This is based on the ‘triple assessment’. The physician will take a history and examine the patient. The radiologist will do a mammogram and/or an ultrasound. The cells of the lump may be sampled, using a fine needle or by taking a core of tissue.
If all of the above suggest the lump is not malignant, the lump may be watched and followed up. If one of the tests casts any doubt, the lump should be removed.
Clinical Assessment: There are two parts to this: the patient’s history and the examination. The general medical history from the patient includes the history of the illness, family history and past medical history of the patient. In a clinical examination, the examiner gently palpates (feels) your breasts, noting shape, texture, changes in skin and nipples and location of any lumps, as well as whether these are attached to skin or deeper tissues. Lymph nodes under the arm and above the collarbone are palpated for swelling.
Mammography: Low-intensity X-ray of the breast. This may be done for screening (if no abnormalities were found in an examination) or for diagnosis. A mammogram takes about 20 minutes and can detect many changes or abnormalities before they grow large enough to be felt. Diagnostic mammography may indicate whether a breast lump is malignant or not.
If the mammogram was done for screening and shows an area of abnormal tissue that is probably benign, you need to return in four to six months for a re-check. If it shows no serious abnormality, regular screening programmes should be adhered to. These include mammographic screening and clinical screening. When the mammogram shows abnormalities, the radiologist may recommend another type of exam, such as a biopsy.
If the mammogram was done as a diagnostic test, the results must be seen in the light of the clinical findings and the biopsy.
What happens during a mammogram? You stand or sit in front of a special X-ray machine while the radiological technologist lifts each breast and positions it on a platform that holds X-ray film. A plastic plate presses the breast against the platform. Pressure for a few seconds means the X-ray dose can be lowered and ensures the X-ray shows as much breast tissue as possible. This pressure is harmless and usually not painful, but it can be uncomfortable. Avoid having mammograms when your breasts are tender, such as before your period.
Discuss results with your doctor. Calcifications are mineral deposits, which may appear as white spots on the film. They may be caused by benign conditions or, less often, by cancer. If the mammogram shows masses, these are usually biopsied if they are not cysts (benign collections of fluid).
Ultrasound or removal of fluid with a needle (aspiration) may confirm whether a mass is a cyst. Some masses are monitored with periodic mammograms; others require biopsy.
Mammograms can suggest but not prove the presence of cancer. Mammography detects 85 to 90 percent of breast cancers. Approximately 10 to 15 percent are not visible on mammography, but are felt on physical examination. Mammograms are more unreliable in woman younger than 40.
Breast ultrasound: Sound waves are bounced off tissues and the echoes converted into a picture (sonogram). Ultrasound helps distinguish between cysts and solid tumours. It is particularly useful in younger patients whose breasts are too dense for mammography.
MRI Scan: This is being done in some specialist centres through out the world. It is very effective in picking up small cancers, especially in young women who have dense breasts. Several studies from Europe have shown that it is useful in screening women who have a genetic susceptibility to cancer. The problem is that it is very expensive and unpleasant for the patient.
Nipple discharge examination: Initially, it is to check for blood. If blood is present a sear is done to check for cancer cells. Clear or milky secretions are very unlikely to result from cancer. A red-brown colour may indicate cancer, although benign conditions are more likely. Even when no cancer cells are found, cancer cannot be ruled out. If a suspicious mass is also present, a biopsy is necessary.
Biopsy (sampling of the tissue): This may be done as part of the assessment of a lump even though the clinical examination and the radiological examination suggest that the lump is not cancerous. Alternatively, an abnormality on a mammogram may be sampled, using special radiological equipment. 80 percent of biopsies are non-cancerous.
Fine-needle aspiration biopsy: A needle is guided into the abnormal area while the doctor palpates the lump. Once the needle is in place, fluid is drawn out. Clear greenish fluid usually indicates a benign cyst. Bloody or cloudy fluid can mean a benign cyst or, rarely, cancer. With a solid lump, tissue cells are aspirated. In most cases, examination under a microscope will determine whether abnormalities are benign or cancerous.
Core needle biopsy: A small cylinder of tissue is removed from an abnormality.
If after the ‘triple assessment’ the lump is suspected to be cancerous, or the diagnosis is still not known, the lump should be removed.
Surgical biopsy: All, or part of a lump is surgically removed for examination. Excisional biopsy removes the abnormality along with a surrounding margin of apparently normal tissue, and is usually considered the first of a two-step procedure (a diagnosis of cancer by needle biopsy can also be considered the first step.)
The second step is complete local treatment of the cancer through radiation therapy or additional surgery. With the two-step procedure for biopsy, a cancer diagnosis is known shortly after biopsy, but the extent of cancer is not known until after local treatment surgery.
If the abnormality is not a lump but a change on a mammogram that cannot be palpated, then the tissue has to be removed, using a technique called a ‘hookwire biopsy’. The patient has another mammogram and the area of concern on the mammogram is located. The radiologist then places a wire into the area using the x-ray machine to guide it into position. The surgeon then cuts out the wire along with the surrounding tissue and sends it to be x-rayed again to check that the abnormal tissue has been removed.
At the moment breast cancer cannot be prevented, but it can be diagnosed much earlier than before. Early diagnosis is possible with routine mammography and early biopsy of suspicious lesions. The earlier cancer is found, the better the chances of a cure.
American specialists advise that women should have a baseline mammogram at the age of 40. Between 40 and 50 years of age, mammograms are recommended every other year. After age 50, annual mammograms are recommended.
Between 20 and 39, women should have a clinical breast examination every three years, and annually from 39 on.
The following may help prevent breast cancer:
- A low-fat diet (less than 20 percent fat), with plenty of fruit and vegetables, and ideal weight maintenance.
- When cancer is found and treated early, there are more treatment choices and a better chance of recovery. Talk to your doctor about symptoms to watch for, and an appropriate check-up schedule.
- Between clinical check-ups, do a monthly breast self-exam (BSE). Every woman's breasts are different, and they change with age, the menstrual cycle, pregnancy, menopause, or taking oral contraceptives or other hormones. It may be normal for your breasts to feel lumpy, swollen or tender at times, such as immediately before a period or during pregnancy. By doing a monthly BSE, after age 20, you learn what is normal for your breasts, and are more likely to detect changes.
- Breast-feeding may slightly decrease risk, especially if continued for 18 to 24 months. Strenuous exercise in youth might provide life-long protection. Even moderate physical activity as an adult can lower risk.
- In certain high-risk groups – women with a strong family history of breast cancer (mother, sister, maternal aunt) – genetic testing looking for mutated genes associatied with an increased risk of breast and ovarian cancers (BRCA 1 & 2) is available. This can be useful as an indication of the potential of developing breast cancer. In certain exceptional cases, bilateral prophylactic mastectomy is used in order to try and reduce the risk of the patient developing a breast cancer later in life.
The treatment of breast cancer depends on the clinical stage of the cancer, the pathological type, as well as the patient’s age and wishes.
Treatment for invasive cancers
Invasive cancers are staged according to the size of the primary breast cancer, the spread to the axillary nodes and evidence of spread elsewhere in the body.
- Stage 1: The tumour in the breast is small and there is no evidence of spread anywhere.
- Stage 2: The primary tumour is < 5cm and there may be evidence of early spread to the lymph nodes.
- Stage 3: The primary tumour is > 5cm or there is evidence of obvious lymphatic spread.
- Stage 4: There is evidence of spread to other organs such as lung, liver or bone.
The treatment may be thought of as being aimed at the primary tumour, the lymph nodes or the whole body.
Treatment plans are divided into local and systemic therapy. Local therapy, such as surgery and radiation, aims to remove or kill cancer cells in the breast and adjacent lymph nodes. Systemic therapy may be in the form of chemotherapy or hormonal therapy. This may mean a tablet once a day or intravenous drugs.
- Stage 1 disease is treated locally, usually with surgery. There is a growing tendency to give patients hormonal therapy, even when the disease is in such early stages.
- Stage 2 disease is usually treated by surgery first and then systemic treatment afterwards. Systemic treatment given after local treatment, when there is no sign of disease, is known as adjuvant therapy.
- Stage 3 disease is increasingly treated with systemic treatment first to ‘downstage’ the disease and with surgery afterwards. Systemic treatment given before local treatment is known as neoadjuvant therapy.
- Stage 4 disease is usually treated systemically, although radiotherapy may be used.
Radiation therapy uses high-energy rays to reduce the size of the tumour or destroy cancer remaining in the breast area after surgery. It may be used to control the local tumour in stage 4 disease, or may be used to treat local recurrence at a later date. It is generally painless and given on an outpatient basis. Side effects include fatigue, swelling and sunburn-like skin changes in the treated area. These changes usually disappear in six to 12 months. Radiation therapy is nearly always given after a lumpectomy.
Cancer can be cured by local therapy if it has not spread further. Unfortunately, cancer can spread, even though the primary cancer is small and there is no evidence of spread to lymph nodes.
Breast cancer does not always follow predictable growth patterns, and a prognosis cannot be predicted with absolute certainty. Therefore, systemic therapy is incorporated to treat the potential and actual risk of cancer spreading.
Chemotherapy and hormonal therapy are systemic therapies, given via the bloodstream to kill cancer cells that have spread beyond the breast. Chemotherapy comprises drugs received intravenously or by mouth. Hormone therapy involves drugs that change the way hormones work, or the removal of hormone-producing organs such as the ovaries. More patients are being put on systemic treatment after apparently curative surgery, as there is increasing evidence that patients are less likely to develop problems, such as recurrence, second primary in the remaining breast tissue or metastatic disease, if they take systemic treatment. The traditional roles of hormonal treatment and chemotherapy are constantly being challenged and are changing, although hormonal therapy in a tablet form is still the most common form of adjuvant therapy.
The surgical options must be considered from various angles: the treatment of the breast, the treatment of the lymph nodes and the question of reconstruction.
Mastectomy means removal of all the breast tissue. If this is done by a breast surgeon, 3 to 5 percent of the breast tissue will still be left between the muscle bundles or in the skin.
Originally, radical mastectomy was done as a standard procedure. It entails removal of the breast, underarm lymph nodes and chest muscles under the breast. Because of disfigurement and side effects, and because modified radical mastectomy has proved equally effective, radical mastectomy is now rarely done.
Modified radical mastectomy entails removal of the breast tissue, the fascia on top of the muscle and the lymph nodes. It is less disfiguring and may be done to achieve a flat chest wall, or may be done through the nipple to allow immediate reconstruction.
Simple or total mastectomy removes the breast, but not underarm lymph nodes nor muscle tissue beneath the breast.
In certain circumstances, if the tumour is < 5cm, breast conservation therapy (BCT) may be a satisfactory option. This maintains the major part of the breast and often shape is not altered significantly. Both BCT and modified radical mastectomy are equally effective in the correct patients. BCT has to be followed by radiotherapy, and so is contraindicated in patients who cannot have radiotherapy. Neither guarantees a cure as approximately 25 to 30 percent of all women with breast cancer ultimately die from their disease. (The chances or dying from the disease are related to the stage of the disease at the time it was first diagnosed.)
The axillary nodes can be dissected out through a separate incision at the time of BCT. If nodes are felt on clinical examination, they will nearly always be removed at the time of surgery. This may be as part of the mastectomy (modified radical mastectomy) or may be through a separate incision.
If there are no nodes palpable and there is no evidence of cancer spread to the axilla, a Sentinel Lymph Node Biopsy may be performed. A radioactive substance is injected into the cancerous region, and is carried by lymph vessels to a "sentinel node", which is the first lymph node receiving lymph from the tumour. If the sentinel node contains cancer, more nodes are removed.
If the sentinel node is cancer-free, additional lymph node surgery is avoided. If there are axillary nodes that are palpable at the time of surgery, then the axillary lymph nodes should be removed surgically (axillary dissection).
If cancer has spread to lymph nodes, risk of recurrence is much higher and chemotherapy and/or hormonal therapy are usually needed.
Risk of metastasis roughly increases with the size of the original tumor, spread to lymph nodes, number of nodes involved and microscopic characteristics of the cancer. No tests can show precisely whether there is microscopic metastasis. Even when the tumor is small and there is no evidence of spread to lymph nodes, there may be reasons to use adjuvant systemic therapy, as about 10 to 15 percent of women in this group will develop metastatic cancer.
Adjuvant therapy is treatment that is given even when there is no evidence of any residual disease. The rationale for giving it is based on the fact that although the breast cancer is early, some women will have another problem from their cancer. Giving extra treatment makes this more unlikely.
Chemotherapy in adjuvant treatment used to involve a combination of drugs, in four or six cycles encompassing about six months of therapy. There are many more regimes that are being used and the advent of new drugs has made it difficult to generalise as to what regime is most suitable.
Side effects from chemotherapy depend on the drug type, amount and length of treatment. Temporary side effects may include nausea and vomiting, loss of appetite, hair loss, mouth sores and menstrual cycle changes. Chemotherapy can damage blood-producing bone marrow cells, resulting in low blood cell counts. A shortage of white blood cells, red blood cells and platelets increases the risk of infection, fatigue and bleeding or bruising respectively. Premature menopause and infertility are potential permanent complications.
Oestrogen promotes growth of some breast cancers. If hormone receptors are present, anti-oestrogenic agents such as tamoxifen can be used. Tamoxifen is taken daily in pill form for two to five years, as adjuvant therapy or to treat metastatic cancer. In post-menopausal women tamoxifen can decrease risk of recurrence similar to the decrease with chemotherapy, without many of the side effects associated with chemotherapy. It can also be given following completion of chemotherapy as, in certain women, it can decrease risk of recurrence more than with chemotherapy alone.
This drug helps women with breast cancer in its early stages, regardless of age. Tamoxifen may increase risk of early stage cancer of the uterine lining. Other effects may include blood clots in the legs (DVT), weight gain, hot flushes, mood swings and cataracts.
On the positive side, Tamoxifen strengthens the bones.
Tamoxifen is the only anti-hormone treatment that can be given to premenopausal women.
Aromatase Inhibitors are a newer form of anti-oestrogen drugs that are being used more frequently in post menopausal women. Trials show them to be as effective or more effective than Tamoxifen. They have different side effects from Tamoxifen and may be used when Tamoxifen is contraindicated, or as a later treatment in a patient who has already had Tamoxifen. Aromatase inhibitors are increasingly being used in combination with Tamoxifen in appropriate patients.
Inflammatory breast cancer is initially treated with chemotherapy, followed by radiation therapy and surgery.
Treatment for non-invasive cancers
Treatment of Ductal Carcinoma In Situ (DCIS) is based on the risk of it evolving into invasive cancer and the fact that it is a curable disease. Treatment options include lumpectomy, lumpectomy with radiation therapy, and simple mastectomy. If the abnormal area is small, then removing this alone may suffice. Further therapy is usually indicated for a larger abnormal area, because risk of recurrence is reasonably high. In 50 percent of cases, recurring cancer is invasive. With simple mastectomy, the cure rate is 98 to 99 percent.
Lobular Carcinoma In Situ (LCIS) is not pre-invasive, but represents high-risk potential for development of invasive cancer. No treatment is required, but affected women should be monitored with mammograms and physical exams. Lumpectomy, with or without radiation, does not significantly decrease the risk of developing invasive breast cancer with LCIS. A single mastectomy is not a solution either, since invasive cancer can occur in either breast.
Side effects and post-surgical recovery
Clearly these depend on the surgery. There are complications from the anaesthetic and those from the operation itself.
After a lumpectomy, it is usual to feel a mass there, which takes months to settle. Eventually, the tissue under the scar will feel similar to the remaining breast tissue, but this takes many months. If immediate reconstruction is done at the time using the patient’s breast skin, there may be more complications relating to skin healing.
If the operation has included removal of the axillary lymph nodes (Modified radical mastectomy, axillary dissection or radical mastectomy) then other side effects may occur. Seroma (a build up of fluid) in the cavity left by surgery is very common. It can usually be simply treated by drainage with a needle and rarely causes a problem. A major but unusual side effect is lymphoedema, which occurs in about 1 percent of women. Lymphoedema is swelling of the arm due to fluid accumulation. It is quite common to get very mild swelling but very uncommon to get marked swelling. It is more common if there has been both surgery and radiotherapy.
The potential for developing lymphoedema remains for life. Injury or infection involving the affected arm can aggravate existing lymphoedema or trigger its development, so the arm and hand should be protected. Avoid having blood drawn from the affected arm, and report swelling, tightness, pain or injury to the arm or hand to your doctor promptly.
There may be temporary or permanent limitations to arm and shoulder movement after surgery. Numbness or pinching/pulling sensations of upper inner arm skin is another common side effect, because the nerve controlling this travels through the lymph node area.
After surgery, you may need drains from the breast or underarm to remove fluid that collects during healing. Fluid must be emptied and measured for about two weeks, while drains remain in place. Some doctors put the arm in a sling, but most encourage moving the arm to avoid stiffness. Most women who have lumpectomy or mastectomy have little pain in the breast area. Written instructions on post-operative care are usually provided for the patient and the caregiver.
Most patients see their doctor within seven to 14 days after surgery. Your doctor should discuss the results of your pathology report as well as further treatment.
Long term follow up (Outcome)
The management of a patient who has been treated for breast cancer includes life-long surveillance. This is to detect any disease progression early and to check if there is a chance of the patient developing a second cancer. After finishing the first course of treatment, it is important to continue with scheduled follow-up appointments. During these appointments, your doctors will ask about any symptoms, do physical examinations and order laboratory or imaging tests, as needed, to look for recurrences or side effects.
At first, follow-up physical exams are done every three to four months. The longer you are free of cancer, the less often exams are needed. After five years, they are done once a year. Annual mammograms of the remaining breast and the breast treated by lumpectomy are needed. Women taking tamoxifen should have annual pelvic examinations.
A chest X-ray, CT scan, bone scan and a biopsy may be done if initial exams and tests suggest a recurrence. Depending on the location of a recurrent cancer, treatment may involve surgery, radiation therapy, hormonal therapy or chemotherapy.
When to see your doctor
If you note any change in your breast, you should see your doctor immediately.
Previously reviewed by Dr Jenny Edge, General Surgeon, BSc, MB BS, FRCS (Edin), M Med (Stell.), September 2006
Reviewed by Dr David Eedes, Oncologist, February 2011